Escala Braden

SENSORY PERCEPTION Ability to respond meaningfully to pressure-related discomfort

COMPLETELY LIMITED – Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation

VERY LIMITED – Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness

SLIGHTLY LIMITED – Responds to verbal commands but cannot always communicate discomfort or need to be turned

NO IMPAIRMENT – Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

MOISTURE Degree to which skin is exposed to moisture

CONSTANTLY MOIST– Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

OFTEN MOIST – Skin is often but not always moist. Linen must be changed at least once a shift.

OCCASIONALLY MOIST – Skin is occasionally moist, requiring an extra linen change approximately once a day.

RARELY MOIST – Skin is usually dry; linen only requires changing at routine intervals.

ACTIVITY Degree of physical activity

BEDFAST – Confined to bed.

CHAIRFAST – Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

WALKS OCCASIONALLY – Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.

WALKS FREQUENTLY– Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.

MOBILITY Ability to change and control body position

COMPLETELY IMMOBILE – Does not make even slight changes in body or extremity position without assistance.

VERY LIMITED – Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

SLIGHTLY LIMITED – Makes frequent though slight changes in body or extremity position independently.

NO LIMITATIONS – Makes major and frequent changes in position without assistance.

NUTRITION Usual food intake pattern

VERY POOR – Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement

PROBABLY INADEQUATE – Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement

ADEQUATE – Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally refuses a meal, but will usually take a supplement if offered

EXCELLENT – Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

FRICTION AND SHEAR

PROBLEM- Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction

POTENTIAL PROBLEM– Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down

NO APPARENT PROBLEM – Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.

Escala Braden

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